A thesis submitted to the School of Graduate Studies in partial fulfillment for the degree of Doctor of Philosophy in Community Health

Evaluating the Implementation of Picture Archiving and Communication Systems in Newfoundland and Labrador

by

Donald M. MacDonald

A thesis submitted to the School of Graduate Studies in partial fulfillment for the degree of Doctor of Philosophy in Community Health

Division of Community Health and Humanities, Faculty of Medicine Memorial University of Newfoundland

September, 2008

Abstract

Evaluating the Implementation of Picture Archiving and Communications System (PACS) in Newfoundland and Labrador

In November 2007, the Newfoundland and Labrador Centre for Health Information (NLCHI) completed implementation of a provincial Picture Archiving and Communication System (P ACS) on behalf of the provincial government. A benefits evaluation was undertaken to determine the impact that this PACS implementation had within the province of Newfoundland and Labrador.

The evaluatio n was carried out on the island portion of the province with a focus on 2 of the 4 provincial Health Authorities. The evaluation was guided by the report Towards an Evaluation Framework for Electronic Health Records Initiatives (Nevi lle, Gates, MacDonald et a! 2004), which emphasizes significant stakeholder involvement at each step of the evaluation, and triangulation of data where ever possible. The evaluation was designed as a pre/post comparative study utilizing project documentation, administrative data, surveys and key informant interviews as the primary data sources.

The findings of this study provide convmcmg evidence that clinicians,

administrators and support staff strongly support the implementation of a

provincial PACS . Factors contributing to the success of the provincial PACS

taken by NLCHI in engaging key stakeholders throughout the implementation, and through this process establishing a sense of ownership within the regional health authorities. The benefits of PACS , in particular, immediate access to historical and current exams and reports from multiple access points 24/7, and site-to-site physician/radiologist consultations, were also seen as key to the success of the P ACS implementation.

The realization of a provincial P ACS did not come without its challenges. From a

clinical perspective, P ACS resulted in a decrease in physician to radiologist

consultations within a site, although this has been offset somewhat by an increase

in consultations between sites. From the administrative side, PACS wa very

costly to implement and to maintain, making it difficult to justify PACS based

solely on a financial costing model. The primary reasons for not achieving a

return on investment for PAC in many sites was a combination of low exam

volume, a pre-ex isting efficient film environment, and the high cost for PACS

hardware, software and ongoing maintenance.

DEDICATION

To my wife Lorraine, and children Jared and Reghan;

Dad's finally finished school

ACKNOWLEDGEMENTS

I would like to thank members of my committee : Professor Doreen Neville, whose dedication, guidance and encouragement was always there; Professor Rick Audas, whose commitment to my research proved invaluable; and Mr. Steve O'Reilly, whose feedback with respect to the technical and editorial aspects grounded my thesis in reality .

Thanks to Canada Health Infoway and the Provincial Department of Health and Community Services for co-funding this study.

I would also like to acknowledge the many health professionals who responded to the surveys, provided administrative data, and participated in the interviews. Their cooperation was greatly appreciated.

Thanks are also extended to the Newfoundland and Labrador Medical Association for their assistance in obtaining data on the provincial physician population.

A special thank you is g1ven staff at the Centre for Health Information, in particular Alison Collier and Maureen Harvey for their administrative support, and all staff of the BIN Department.

I would also like to thank my parents, Margaret and Wally, who instilled in me

the value of education.

TABLE OF CONTENTS

Abstract List ofTables List of Figures

CHAPTER 1: INTRODUCTION

1.1 Electronic Health Record Initiatives: Canada and Newfoundland and Labrador

1.2 History of Picture Archiving and Communication Systems (P ACS)

1.3 The Role of P ACS in the Newfoundland and Labrador EHR Initiative

1.4 Research Questions 1.5 Objectives of the Study

CHAPTER 2: LITERATURE REVIEW 2.1

2.2 2.3 2.4 2.5

Conceptual Benefit Evaluation Frameworks Evaluation Perspectives

Challenges to Evaluation of EHR Initiatives Previous Evaluations of PACS Initiatives Benefits Evaluation Framework for P ACS 2.5.1 Canada Health Infoway 's Evaluation

Framework for P ACS

2.5.2 Newfoundland and Labrador's Evaluation

11

IX

Xll

13 16 18 18

20 20

29

33 39 56 56

Framework for P ACS 61

CHAPTER 3: METHODS 69

3.1 3.2 3.3 3.4

Evaluation Approach Study Design

Study Setting Study Instruments

3.4.1 Survey Questionnaires

3.4.2 Key Informant Interview Script 3.4.3 Administrative Data

3.4.3.1 Benefit Measures : Canada

69 69

70

76 76

77

78

3.5 3.6

3.7

CHAPTER4: RESULTS

3.4.4 Total Cost of Ownership Ethics

Data Collection

3.6.1 Pre-Evaluation Workshop

3.6.2 Pre and Post PACS Administrative Data 3.6.3 Pre PACS Surveys

3.6.4 Post PACS Surveys 3.6.5 Key Informant Interviews Data Analysis

3. 7.1 Survey Questionnaires

3 .7.2 Administrative Data

3.7.3 Key Informant Interviews

86 86 87 87 89 90 91 93 97 97 98 100

102

4.1 Key-Informant Workshop 102

4 .2 Surveys 104

4.2.1 Administration of Questionnaires l 04 4.2.2 Questionnaire: Classification of Level of

Agreeme~

105

4.2.3 Classification of Percent Agreement l 06 4 .2 .4 Comparative Analysis I 06

4.2.5 Survey Response Summary 109

4.2 .6 Survey Results I 09

Demographics I 09

Film Environment - Physician II5 Benefits of P ACS - Physician II9 Challenges ofPACS - Physician 122 Benefits of P ACS - Physician/Radiologist 124 Challenges of P ACS -

Physician/Radiologist I27

Benefits/Challenges by Experience 129 Benefits/Challenges - Technologists 137

Open Ended Question 139

4.3 Administrative Data 147

4.4 Project Management Documents 172

4.4.1 Total Cost of Ownership 172

4.4.1.1 Total Cost of PACS Ownership:

Province 2005/07 I76

4.4.I.2 Total Cost of PACS Ownership:

Terrier Health Authority 2005/07 178

4 .5 Key Informant Interviews 181

4 .5.1 Perceived Benefits 182

4.5.2 Unintended Consequences 194

4.5.3 Gaps in the Implementation Process I97

4.5.5 Lessons Learned 204

4.5.6 Change Management 208

4.5.7 Overall Perceptions 209

CHAPTER 5: DISCUSSION OF RESULTS 212

5.1 Perceived Benefits ofPACS 212

5.1.1 Expediting Review of Exam 215

5.1.2 Easier Access to Exams 217

5.1.3 Improved Patient Care/Outcomes 218

5.1.4 PACS Functionality 223

5.1.5 Improved Quality of Reports 224

5.1.6 Improved Efficiency 225

5.1.7 Report Tum-Around-Times (TAT) 228

5.1 .7.1 Terrier Health Authority 228

5.1.7.2 Mastiff Health Authority 233 5.1.8 Reduced Hospital Length of Stay (LOS) 237 5.1.9 Professional Consultations 239 5.1.10 Previous Experience with PACS: Benefits 241 5.2. Perceived Challenges of PACS 243

5.2.1 Access to PACS 243

5.2.2 Image Quality 246

5.2.3 PACS Functionality 247

5.2.4 System Support 248

5.2.5 Training 250

5 .2.6 Previous P ACS Experience: Challenges 251 5.3 Total Cost of Ownership (2005/07): Province 253 5.4 Total Cost of Ownership (2005/07):

Terrier Health Authority 257

5.5 Return on Investment: Terrier Health Authority 258 5.6 PACS and the Provincial EHR Strategy 265 5.7 Key Facilitators and Barriers to Successful

Implementation 272

5.7. 1 Key Facilitators 272

5.7.2 Key Barriers 275

5.8 Lessons Learned and Recommendations 279 5.9 Challenges in Carrying out the Evaluation 283 5.10 National PACS Benefit Measures 293 5.11 Other Provincial PACS Evaluations 297

5.12 Limitations of the Study 302

CHAPTER 6: SUMMARY OF RESEARCH, IMPLICATIONS OF FINDING

AND CONCLUSION 304

REFERENCE LIST

APPENDIX A

APPENDIX B-1 APPENDIX B-2 APPENDIX C-1 APPENDIX C-2 APPENDIX D

APPENDIX E-1

APPENDIX E-2

APPENDIX F APPENDIX G-1

APPENDIX G-2

APPENDIX G-3

APPENDIX H

APPENDIX I

6.2 Implications of Findings

6.2.1 Future Implementations of P ACS 6.2.2 Future Evaluation of P ACS 6.2.3 Conclusion

Number of Beds by Acute Care Site: Newfoundland (Excluding Labrador) - As of December 2007

Pre PACS Opinion Survey: Radiologists/Technologists Post P ACS Opinion Survey: Radiologists/Technologists Pre P ACS Opinion Survey: Referring Physicians

Post P ACS Opinion Survey Referring Physicians RationaleNalidation for Survey Questions:

Literature Review

Key Informant Interview Scripts

Project Managers/DIIIT Directors/P ACS Administrators Key Informant Interview Scripts

Physicians/Radiologists/Radiology Technologists Ethics Approval Letters

Key Informant Interview Scripts Initial E-Mail Script to Seek Interview Key Informant Interview Scripts

Follow-Up telephone Script to Seek Interview Key Informant Interview Scripts

Follow-up Telephone Script to Initiate Interview Key Informant Interview Scripts

Elements of Consent Document Key Informant Interview Scripts

Modified Telephone Script to Seek Interview (No Physician E-Mail)

309 309 310 311 313

331 333 338 343 347

352

361

362 364

371

373

374

376

379

APPENDIX J

APPENDIX K

Findings of September 28, 2005 Pre P ACS

Benefit Evaluation Workshop 381

Detailed Survey Response Rates by Region and Profession 389 APPENDIX L-1 Referring Physicians: Pre PACS Implementation Survey

Terrier Health Authority 400

APPENDIX L-2 Referring Physicians: Post PACS Implementation Survey

Terrier Health Authority 408

APPENDIX L-3 Referring Physicians: Post PACS Implementation Survey Mastiff , Spaniel and Terrier Combined 413 APPENDIX L-4 Radiologists: Pre PACS Implementation Survey

Terrier Health Authority 419

APPENDIX L-5 Radiologists: Post PACS Implementation Survey

Terrier Health Authority 426

APPENDIX L-6 Radiologists: Post PACS Implementation

Mastiff, Spaniel and Terrier Combined 431 APPENDIX L-7 Radiology Technologists: PreP ACS Implementation

Terrier Health Authority 436

APPENDIX L-8 Radiology Technologists: Post PACS Implementation

Terrier Health Authority 443

APPENDIX M Report Turn-Around-Times (TAT) by Modality by Site

Terrier Health Authority 449

APPENDIX N Report Turn-Around-Times (TAT) by Modality by Site

Mastiff Health Authority 465

LIST OF TABLES

Table Page

3-1 Population (2006) by Health Authority

Newfoundland and Labrador 71

3-2 PACS Go-Live Date by Site and Evaluation Tools Used 75

3-3 Pre PACS Surveys: Terrier Health Authority 91

3-4 Post P ACS Surveys Mailed-out

Mastiff, Spaniel and Terrier Health Authorities 93

3-5 Key Informant Documents and Guides 95

3-6 Key Informants Contacted for Interview 96

4-1 Additional Research Questions and Indicator Measures 103 4-2 Sample Size: Pre and Post PACS Survey

Mastiff, Spaniel and Terrier Health Authorities 107 4-3 Survey Response Summary: Pre and Post PACS

Mastiff , Spaniel and Terrier Health Authorities 109 4-4 Physicians Demographics: Pre and Post P ACS

Terrier Health Authority I 1 1

4-5 Physicians Demographics: Post P ACS

Terrier, Mastiff and Spaniel Health Authorities (Combined) 112 4-6 Radiologist Demographics: Post P ACS

Terrier, Mastiff and Spaniel Health Authorities (Combined) 113 4-7 Radiology Technologists Demographics : Pre and Post PACS

Terrier Health Authority 115

4-8(A) Physicians Film Environment: Pre PACS Implementation

Terrier Health Authority 116

4-8(B) Physicians Film Environment: Pre PACS Implementation

4-9 Physicians Perceived Benefits ofPACS: Pre and Post PACS

Terrier Health Authority 121

4-10 Physicians Perceived Challenges ofPACS: Pre and Post PACS

Terrier Health Authority 123

4-11 Physicians/Radiologists Perceived Benefits ofPACS: Post PACS Terrier, Mastiff and Spaniel Health Authorities (Combined) 126 4-12 Physicians/Radiologists Perceived Challenges ofPACS : Post PACS

Terrier, Mastiff and Spaniel Health Authorities (Combined) 129 4-13 Physicians Perceived Benefits of PACS by Previous Experience:

Post PACS

Terrier, Mastiff and Spaniel Health Authorities (Combined) 132 4-14 Physicians Perceived Challenges ofPACS by Previous Experience:

Post PACS

Terrier, Mastiff and Spaniel Health Authorities (Combined) 135 4-15 Radiology Technologists Perceived Benefits of P ACS:

Pre and Post P ACS

Terrier Health Authority 137

4-16 Radiology Technologists Perceived Challenges of PACS:

Pre and Post P ACS

Terrier Health Authority 139

4-17 Survey Respondents Including Comments 140

4-18 Summary of Type of Comment Provided 141

4-19 Summary Content of Physician Comments

Pre and Post PACS Survey 144

4-20 Summary Content of Radiologists Comments

Pre and Post P ACS Survey 145

4-21 Summary Content ofTechnologists Comments

Pre and Post P ACS Survey 146

4-22 Summary of Data Availability for Twelve (12) Benefit Indicators 147

4-23 Exam Total by Modality and Site -Terrier Health Authority 155

4-24 Average Monthly TAT by Modality and Site

Terrier Health Authority 156

4-25 Exam Total by Modality and Site- Mastiff Health Authority 157 4-26 Average Monthly TAT by Modality and Site

Mastiff Health Authority 158

4-27 Summary ofTransition from Film to PACS (Modalities in Scope)

Terrier Health Authority 159

4-28 Total P ACS Implementation Costs -Terrier Health Authority 162 4-29 PACS Hardware Depreciation Schedule -Terrier Health Authority 163 4-30 Film Environment Costs- Terrier Health Authority 165 4-31 P ACS Environment Costs - Terrier Health Authority 166 4-32 P ACS Implementation Costs (Hardware/Software Depreciated)

Terrier Health Authority 167

4-33 Cost per Exam in Film Environment Compared to P ACS

Terrier Health Authority 169

4-34 Cost Per Exam in PACS: Constant Payments and Interest Rate 171 4-35 Estimated Costs PACS Project Management Office (2005/07)

Newfoundland and Labrador 176

4-36 Estimated Costs for Implementation and Equipment (2005/07)

Newfoundland and Labrador 177

4-37 Total Estimated PACS Implementation Costs (2005/07)

Newfoundland and Labrador 178

4-38 Professional Costs (2005/07) - Terrier Health Authority 179 4-39 Technical Environment (2005/07)- Terrier Health Authority 180 4-40 Summary ofTotal Cost of Ownership (2005/07)

Terrier Health Authority 181

4-41 Summary of Key-Informants Contacted/Interviewed 182

5-1 Total Cost ofPACS Ownership (2005/07)

Newfoundland and Labrador 255

5-2 Total Cost of PACS Ownership (2005/07) Including NLCHI

In-Kind Contributions -Newfoundland and Labrador 257 5-3 Total Cost of PACS Ownership (2005/07) Including NLCHI

In-kind Contributions - Terrier Health Authority 258

5-4 Summary ofNational PACS Benefits Framework 296

LIST OF FIGURES

Figure Page

Newfoundland and Labrador Health Boards (1994-2003) 15 2 Newfoundland and Labrador Health Authorities (2004-present) 72

3 Tota l Exams by Fiscal Year: Terrier Health Authority 160

Chapter 1 Introduction

1.1 Electronic Health Record (EHR) Initiatives: Canada and Newfoundland and Labrador

For this study, a benefits evaluation was carried out on the implementation of Picture Archiving and Communication Systems (P ACS) in the province of Newfoundland and Labrador, recognizing that PACS is only one of several information systems that will ultimately encompass the provincial Electronic Health Record (EHR). Specifically, this research focused on the P ACS implementation in the Western Health Authority of the province, with select components of the study design carried out in the Central and Eastern Authorities.

While other information systems (e.g., Pharmacy, Telehealth, Laboratory) considered part of the EHR are out of scope for this evaluation, it is nevertheless important to understand how P ACS fits in with the overall EHR implementation plan from both a national and provincial perspective, and the role that the Newfoundland and Labrador Centre for Health Information plays m implementing the provincial EHR.

Canada

An Electronic Health Record (EHR) is a virtual network linking major clinical

and administrative information systems together to allow authorized health care

providers secure access to a patient's key health history and care within the health system. In Canada, the federal government established Canada Health Infoway (lnfoway) in 2001 to accelerate the development and adoption of the Electronic Health Record (EHR) in all provinces. Infoway was provided with $1 .2 billion in funding and a 7-year mandate to work with all jurisdictions in Canada in both planning and implementing their EHR initiatives. A further $400 million was provided to Infoway in the 2007/08 Federal budget. Infoway' s goal is to have 50% of Canadians connected to an EHR by the end of2010.

In their 2003/04 Business Plan, Infoway identified six core components of an EHR: (1) unique personal provider/client registries, (2) pharmacy network, (3) laboratory network, (4) telehealth, 5) public health surveillance, and (6) diagnostic imaging. Each of these EHR components is briefly described:

1) Unique Personal Provider/Client Registries

Registries are considered the foundation of any EHR solution. Clients and providers of the healthcare system, as well as locations where health services are provided, have to be accurately identified in order to achieve the full benefits of an EHR (Canada Health Infoway Infosheet - Registries

http://www.infoway-nforoute.ca/Admin/Upload/Dev/Documentllnfosheet_E_Reg_Final.pdf).

2) Drug Information Systems

Drug Information Systems (DIS) will allow access by authorized health professionals to a client's complete medication profile. By capturing all drugs and dosages prescribed, the DIS will provide physicians and pharmacists with accurate data that will support improved patient care. (Canada Health Infoway Infosheet - Drugs).

http://www. infoway- inforoute. cal Adm in/Up load/ Dev/Document/1 nfosheet_ E _ Drug_Final. pdf

3) Laboratory Network

Having access to on-line laboratory test results will enhance decision-making and case management at the point of care. On-line access to laboratory results will reduce unnecessary duplicate tests and support quicker diagnosis and ultimately, improved patient care (Canada Health Infoway Infosheet - Labs).

http://www. in foway- inforoute.cal Admin/Upload/Dev/ Document/1 nfosheet_ E _Lab _Final . pdf

4) Te/ehealth

Telehealth is the provision of health services through telecommunications technologies. Existing telehealth networks in Canada are already instrumental in bringing healthcare access to many remote and rural communities.

Infoway 's investment in telehealth has two goals: 1) to increase utilization and

sustainability of existing telehealth networks, and 2) to encourage further

expansion of telehealth programs into remote communities (Canada Health

Infoway Infosheet - Telehealth).

http://www. in foway-inforoute.ca/ Adm in/Upload/Dev/Document/1 n fosheet_ E _ TH _Final. pdf

5) Public Health Surveillance

The Public Health Surveillance Strategy will concentrate on the management of communicable diseases, major outbreaks and immunization programs.

Once implemented, Public Health Surveillance will enhance the ability of jurisdictions to provide health alerts, as well as allow for the release of quality

data and associated reports (Canada Health Infoway Infosheet - Public Health Surveillance).

http://www. in foway- in foroute.ca/ Adm in/Upload/Dev/Document/1 n fosheet_ E _PH _Final. pdf

6) Diagnostic Imaging

lnfoway's Diagnostic Imaging (DI) Program envisions a system that will allow radiology Images and reports to be shared by authorized health professionals in different locations across the country. This approach, referred to as a "shared services" approach, requires that a single DI repository be installed in one hospital which then serves as the " hub" for all healthcare facilities in the area. Authorized healthcare providers across the nation would be able to access this information, if necessary. (Canada Health Infoway Infosheet - Diagnostic Imaging).

http://www. infoway-inforoute.ca/ Admin/Upload/Dev/Documentlln fosheet_ E _ Dl_Final.pdf

In addition to these six (6) core components of an EHR, Infoway is also investing in four additional strategic programs in Canada: 7) Interoperable EHR Systems, 8) Innovation and Adoption, 9) Infostructure, and 1 0) Patient Access to Quality Care:

7) Interoperable EHR Systems

Solutions that allow health professionals to view and update an integrated patient health record from anywhere, at any time.

http://www.infoway-inforoute.ca/ Admin!Upload/Dev/Document/Infosheet_ E _IEHR _Final.pdf

8) Innovation and Adoption

Projects that provide a catalyst for the implementation and adoption of

electronic health record solutions in Canada.

http://www. infoway-in foroute.cal Adm in/Upload/Dev/Document/1 n fosheet E lnnAd Final.pd f

9) Infostructure

The development of common architectures and standards that support the interoperability of electronic health record solutions.

http://www.infoway-inforoute.ca!Admin/Upload/Dev/Document/lnfosheet_E_Info_Final.pdf

I 0) Patient Access to Quality Care Program

The Patient Access to Quality Care (PAQC) investment program was

established in the fall of 2007. This $50 million program is aimed at improving

timely access to services across the continuum of care. It is expected that 5-8 projects will be funded across Canada in 2008, with the goal of reducing patient wait times via the use of technology in both clinical and administrative environments.

http://www.infoway-nforoute.ca/Admin/Upload/Dev/Document/EHRnews_ Winter2008_EN.pdf

In their 2006/07 annual report Canada Health Infoway reported that they had committed approximately $1.14 Billion out of their total budget of $1.266 Billion across the nine (9) program areas. (Canada Health Infoway Annual Report 2006/07). Partnerships with Infoway generally require investments by a jurisdiction of between 25%-50% of the eligible costs for any specific project.

Newfoundland and Labrador

In Newfoundland and Labrador, the Health System Information Task Force was

established in 1993 by the Department of Health, the Newfoundland Hospital and

Nursing Home Association, and Treasury Board. The Task Force was mandated

to review the current provincial health information system, develop a vision that

would reflect the concept of improved health through improved information, and

make recommendations on how this vision could be realized. The final report of

the Task Force was delivered to government in July 1995, and included 24

recommendations on how the province could improve health through improved

information. The most important recommendation was for government to establish the Newfoundland and Labrador Centre for Health Information (NLCHI), with a mandate to deliver on the rema1mng twenty-three recommendations.

In October 1997, the Newfoundland and Labrador Centre for Health Information became operational. The Centre's vision is to improve the health and well-being of the people of Newfoundland and Labrador by making quality health information available to the public, health professionals, government, regional health authorities, and other organizations and agencies. T he Centre also has the responsibility for the implementation and project management of a province-wide Health Information Network (HIN). The HIN will allow health professionals to electronically share information with each other.

As well as having the challenges all new organizations experience in starting up,

NLCHI had the additional burden of delivering a Health Information Network

with no funding; government approved the establishment of NLCHI on the

condition that funding for the HIN be found within the existing health system

funding envelope. In a province that had a history of failure with large

technology projects, in addition to running consecutive budget deficits, NLCHI's

mandate to deliver a HIN for the province appeared daunting.

The first task undertaken by NLCHI in 1997 was to consult with over I ,000 stakeholders in the province. These consultations were used to educate key stakeholders in the province on the vision of a provincial HIN, and to garner support for the provincial HIN vision. These consultations were completed in February 1998 . At the same time the consultations were being conducted, NLCHI contracted with KPMG Consulting to prepare an Information Systems Strategic Plan. This plan was completed in March 1998 and confirmed that the vision developed by the Health System Information Task Force in 1995 was still valid.

The Centre's original vision was guided by the principles that the HIN would be:

a) secure, confidential and private, b) based on common standards, c) subscribe to the fundamentals of open system architecture, d) viewed as a strategic resource, and e) person centered.

In spite of the overwhelming support from the health system, and validation of NLCHI 's vision by an external consulting group, there was still no substantive funding forthcoming from government for the HIN. Faced with this challenge, NLCHJ ' s Board of Management approached government in April 1998 and received approval to develop a Benefits Driven Business Case (BDBC).

Completed in October 1998, the BDBC presented government with an

incremental approach to the implementation of the HIN, whereby the building of

early phases of the HIN would provide savings to government. These savings

could then be redirected at those areas of the HIN that did not provide financial savings, but were nevertheless critical to its overall success.

The BDBC presented government with an eight phase implementation plan for the provincial HIN. The sequence of implementation was as follows:

1. Unique Personal Identifier/Client Registry

2. Personal Medication Dispensing History (i.e., Component of Pharmacy Network)

3. Personal Diagnostic Service History (i.e. Diagnostic Imaging and Laboratory) 4. Diagnostic Service Requestor Decision Support

5. Personal Medication Regimen (i.e., Component of Pharmacy Network) 6. Personal Health Information Profile

7. Physician Practice Pattern Profiling 8. Clinician Decision Support Tools.

The BDBC recommended the implementation of the first two phases of the HIN:

the Unique Personal Identifier/Client Registry and the Personal Medication

Dispensing History (i.e., Pharmacy Network), given these two phases had the

greatest potential for providing government with financial savings within the

existing health system. Each of these initiatives is described in more detail below.

Unique Personal Identifier/Client Registry

The Unique Personal Identifier/Client Registry is a provincial information system for identifying patients and clients of the health system. It is a cross-referenced index of numbers (i.e. identifiers) assigned to individuals, including: insurance number, hospital number, file number, and computer generated numbers.

The BBDC identified significant potential savmgs from the introduction of a UPI/Client Registry because of its impact on the provincial health insurance system. The Newfoundland and Labrador population has always been mobile, as economic hardships forced residents to seek employment in other parts of Canada.

However, the closure of the cod fishery in 1992 significantly increased the

numbers of people leaving the province in search of work. A study completed by

the Provincial Ministry of Health in 2002 reported that the province experienced a

net loss of approximately 80,000 residents from 1982 - 1998 (Valvasori et al,

2001 ). The study suggested that approximately 40,000 of these residents

continued to hold a valid provincial health insurance card, with a significant

number (approximately 50%) continuing to present their Newfoundland insurance

card when seeking services in their new province of residence. The study

concluded that if the province was able to accurately track residents of the

province, and identify former residents that have a valid health insurance card

from Newfoundland and Labrador, the reciprocal billing program, used to pay for

health services provided to residents outside the province, would be reduced by approximately $1.2 million annually.

In May 2000, nineteen months after the BDBC was originally submitted to government, approval was given to proceed with the implementation of the Newfoundland and Labrador Unique Personal Identifier/Client Registry. In May, 2002 the Client Registry was completed at a cost of approximately $3.5 million to the government of Newfoundland and Labrador.

In January 2003, NLCHI began a project to enhance the existing client Registry with $5.4 million in funding provided by Infoway. In the summer of 2005, NLCHI completed enhancements to the Client Regis try. With lnfoway' s investment the Newfoundland and Labrador Client Registry became what is known as a "Best of Breed" registry, and is now the accepted standard for EHR projects across Canada.

Personal Medication Dispensing History (i.e., Pharmacy Network)

A Personal Medication Dispensing History involves linking community and

hospital pharmacies and physician offices, so that a patient's historical and current

medication profile is available to health professionals at the point of care. The

BDBC suggested that the Personal Medication Dispensing History would deliver

savings to the health system by reducing adverse drug events (ADEs), both in the community and the hospital settings. With accurate real-time prescription profiles available, health professionals would be able to intervene before an adverse event occurs. Such interventions would reduce emergency room visits, hospital admissions and extended lengths of stay. The Personal Medication Dispensing History would also result in more appropriate prescribing and dispensing, recognition of contraindications, improved counseling, improved compliance monitoring and reduced abuse of prescription drugs. The BDBC identified approximately $4.1 million in annual savings to the health system following the implementation ofthe provincial Personal Medication Dispensing History.

In May 2002 the provincial government gave approval to NLCHI to carry out a Pharmacy Network (i.e., Personal Medication Dispensing History) project scope.

A project scope is a high level analysis that determines the required functionality of an information system, and the resources needed for its implementation. The project scope was completed and submitted to government in April 2003. This was followed by further dialogue and clarification, during which time government was provided additional information in support of the Pharmacy Network. In October, 2004 government approved NLCHI moving forward with 1ssumg a Request for Proposals (RFP) for implementation of the Pharmacy Network.

Following a lengthy process a preferred vendor was selected in June 2006 to work

with NLCHI in implementing the Pharmacy Network. Also in June, the provincial

government and Infoway signed an agreement to partner on the implementation. It is expected that the Newfoundland and Labrador Pharmacy Network will "go live" in early 2009.

1.2 History of Picture Archiving and Communication Systems (PACS)

Picture Archiving and Communication Systems (P ACS) present an opportunity to radically change film-based radiology services both inside and outside the hospital setting. In the past, the usual medium for capturing, storing, retrieving and viewing radiology images was hard copy film. The idea to replace film with digital images was first conceptualized in 1979 (Huang 2002). However it was not until the early 1980s that advances in technology made introducing P ACS into radiology departments feasible (Duerinckx, 2003). PACS replaces the film environment with an electronic means to communicate and share radiology images and associated reports in a seamless manner between health professionals.

Prior to the creation of Canada Health Info way in 2001 , P ACS implementations

in Canada were generally funded either by provincial governments, regional

health authorities, or individual institutions (e.g. , hospitals). During the period

from 1998-2002, the province of Newfoundland and Labrador implemented

PACS on a project basis across its eight (8) regional health authorities that existed

until 2003 (Figure 1). In 1998, the Central East Health Region installed the first

regional PACS in the province, and in 2001 , the CHIPP/Tele-i4 initiative added PACS in four more regions: Avalon, Central West, Peninsulas, and the Janeway Hospital, which is located in the St. John ' s Region. In 2002 the Grenfell Health Region implemented P ACS, and in early 2005 the Health Care Corporation of St.

John' s completed its PACS. Following the implementation of PACS at the

Health Care Corporation of St. John ' s, approximately 70% of Newfoundland and

Labrador service delivery areas had PACS capability, although the se PACS were

not inter-connected and could not communicate beyond the local installation.

Figure 1

Newfoundland and Labrador Health Boards (1994-2003)

lnstitutiotud Heulth Bo1n ds

Newfbumlmhnd Labndor

Health Care Co:tporation of St. Jolut's Avalon Health Care Institutional Board

Peninsulas Health Care Co:tporation

Central East health Care Institutional Board Central West Health Co:tporation

Western Health Care Co:tporation

Grenfell Regional Health Senices Board

Health Labrador Co:tporation

There are also several jurisdictions in Canada that have, or will be implementing PACS, as a result of Infoway's Diagnostic Imaging Investment Program. These PACS have either been specific to one hospital, a group of hospitals (i.e., enterprise-wide), or implemented across a regional Health Authority (e.g. , Fraser Health in British Columbia). Infoway reported that at the end of March 2007, they had partnered on 26 separate P ACS initiatives across the I 0 provinces and territories in Canada. Of these projects 8 had been completed, and 18 were ongoing (EHRnews@Infoway Newsletter, Summer Edition 2007).

www.infoway-inforoute.ca/Admin/Upload/Dev/DocumentJEHRNews_Summer%2007_EN.pdf

1.3 The Role of PACS in the Newfoundland and Labrador EHR Initiative

The province of Newfoundland and Labrador was well positioned in 2002 to be early beneficiaries of Infoway funding, given the province had been planning its own EHR since 1998.

In the fall of 2005, lnfoway and the Newfoundland and Labrador government

partnered on a $23 million initiative to implement the first province-wide P ACS

in Canada This initiative had two overall objectives: (1) to implement PACS in

selected rural sites where no PACS currently existed, and 2) to address gaps in

those regions where P ACS was currently operational.

As noted, P ACS was operating in several regions for a number of years, although there were increasing concerns with the quality and capacity of image storage, the long-term sustainability of these systems, and their disaster recovery capabilities.

Another concern was that some of the regions with existing P ACS had yet to achieve a 95% filmless state, resulting in minimal savings (e.g., elimination of film costs). These reduced savings did not offset the initial or ongoing maintenance costs of PACS . Also, as a result of the project based approach for the implementation of these earlier P ACS, there existed no provincial standards with respect to image referral or interoperability. These gaps needed to be addressed so that P ACS would be able to integrate with the full provincial EHR.

The provincial VISion for PACS was one that would provide access to: Any patient, Any image, Any report, Anywhere and Anytime (A

In realizing this vision, referring physicians and radiologists could view their patient's Images and/or reports in a hospital , their office, or even in their homes .

With the Client Registry operational and the Pharmacy Network and PACS being

implemented, the first three phases of the EHR in Newfoundland and Labrador

originally envisioned by NLCHI in 1998, is expected to become a reality by the

Spring of 2009. As of March 2008 , NLCHJ continues to work with Infoway on

several other EHR partnership opportunities, including telehealth, laboratory and

Interoperable EHR Systems (iEHR).

1.4 Research Questions

The key research questions for this study were:

I) Did PACS improve access (for patients) and increase efficiencies (for health professionals) that ultimately lead to enhanced patient care?

2) What are the perceived benefits of PACS from a user perspective, and did they change over time?

3) How do the benefits of PACS compare between rural and urban areas of the province?

4) What are the challenges in measuring the benefits of PACS in a province with a small population dispersed over a large geographical area?

1.5 Objectives of the Study

The objectives of the study were:

1. To validate and measure the benefits arising from the implementation of the provincial PACS (excluding Labrador) with a particular focus on:

a) Improved accessibility to services for patients b) Improved quality of patient care

c) Improved efficiencies of health care providers d) User satisfaction with PACS;

2. Where data is available, compare PACS benefit measures in Newfoundland with P ACS benefits evaluations carried out in Nova Scotia, British Columbia and Ontario;

3. To describe the implementation of the provincial PACS within the context of other key strategies in the province (i .e. , the Electronic Health Record (EHR) and the Electronic Medical Record (EMR);

4. To document the total cost of ownership of the provincial PACS and

5. To identify and describe the key facilitators and barriers to a successful implementation ofPACS;

6. To document the lessons learned from implementing PACS;

7. To document the challenges in carrying out a PACS benefit evaluation.

The research study is presented as follows. In Chapter 2, a literature review sets the stage

by: (1) providing an overview of the various approaches currently used in evaluating the

benefits of new technology; (2) summarizing previous PACS benefit evaluations; and (3)

presenting a review of EHR benefit evaluation frameworks developed both at the national

and provincial levels. Chapter 3 provides details on the various methodologies selected to

maximize success in achieving the study objectives, while Chapter 4 presents a summary

of the study results. A discussion of the results within the context of the study objectives

is provided in Chapter 5, followed by a summary of the research findings and concluding

remarks (Chapter 6).

Chapter 2 Literature Review

The literature review provides an overview of the following: (1) conceptual benefit evaluation frameworks, (2) various perspectives on how to approach benefit evaluations, (3) challenges faced when undertaking a benefit evaluation, ( 4) previous PACS evaluations, and (5) EHR benefit evaluation frameworks developed both at the national and provincial levels.

Authors Note: Sections 2.1 and 2.2 were derived from the report Towards an Evaluation Framework for Electronic Health Records Initiatives: A Proposal For an Evaluation Framework (Neville, Gates, MacDonald et a/, 2004) for which the researcher was a co- author.

2 .1 Conceptual Benefit Evaluation Frameworks

Several conceptual frameworks deve loped for guiding benefit evaluations of

information systems have been published in the literature. These frameworks are

diverse and can focus on one or more specific areas of evaluation (e.g., indicator

measurement/selection, methodologies, processes, etc.).

Information Systems (IS) Success Model

Perhaps the most widely known framework developed for guiding benefit evaluations of information systems is the Delone and McLean Information Systems (IS) Success Model (Delone and McLean 1992). The authors put forward six (6) major dimensions of measurement: 1) system quality, 2) information quality, 3) use, 4) user satisfaction, 5) individual impact, and 6) organizational impact. Each is described briefly below.

System quality measures: engineering-oriented characteristics of the systems, such as response time, ease of use, system reliability, system accessibility, system flexibility and system integration.

Information quality measures: includes perceptions of information accuracy, timeliness, completeness, reliability, conciseness, and relevance, addressed mostly from the perspective of the user (subjective measures).

Measures of information use: includes use by whom, frequency of use and extent of use; valid only if system use is not mandatory.

Measures of user satisfaction: subjective measures, addressed mostly

from the perspective of the user.

Individual impact measures: measures of performance, such as quality of decision making, change in decision behavior, time efficiency of task accomplishment, and time to (and confidence in) decision making.

Measures of organizational impact: employed mainly in the business sector and includes measures of cost reduction, cost effectiveness, contribution to profitability and return on investment (ROI).

The authors emphasize that it is important to study the interrelationships among these dimensions, to avoid arbitrarily selecting items from among the dimensions, and to combine measures from dimensions to create a comprehensive measurement instrument. Furthermore, they suggest that the selection of measures should consider contingency variables, such as the independent variables being researched, the size, structure, strategy and environment of the organization being studied, and the characteristics of the system itself.

In 2003, DeLone and McLean published a ten-year follow-up to their original IS

Success Model article (DeLone and McLean, 2003), in which they looked back on

how their model was applied, and whether it was validated or challenged by

researchers over the last decade. The authors also put forward several refinements

to their original framework including: ( 1) adding a third dimension, "service

quality" to the two original system characteristics, "system quality" and

"information quality", (2) substituting "intention to use" for "use" as a measure of system usage, and (3) combining the " individual impact" and "system impact"

variables into a "net benefits" variable.

Sociallnteractionist Models

Bonnie Kaplan at the Center for Medical Informatics (Yale University School of

Medicine) puts forward the social interactionist model (Kaplan 1997, 1998). This

model is grounded on the interactions between individuals, systems and

organizational characteristics, and considers not only the impact of the

information system on the organization, but also the impact of the organization on

the information system. Measures of benefits within the interactionist framework

are categorized with the "4 C's": Communication (i.e., what are the anticipated

long term impacts on the ways that departments linked by computers interact with

each other?), Care (i.e., what are the anticipated long term effects on the deli very

of medical care?), Control (i .e., will system implementation have an impact on

control in the organization?), and Context (i.e., to what extent do medical

information systems have impacts that depend on the practice setting in which

they are implemented?). Kaplan proposed five methodological guidelines for

developing a comprehensive evaluation framework: (1) focus on a variety of

technical, economic and organizational concerns, (2) use multiple methods, (3) be

modifiable, ( 4) be longitudinal, and (5) be both formative and summative (Kaplan 1997).

Cognitive Evaluation Approaches

Cognitive evaluation approaches employ a variety of methods including scientific, simulations, and naturalistic approaches. Kushniruk, Patel and Cimino (1997) identified the need for improved methodologies for the assessment of health information systems and their user interfaces, noting conventional methods of evaluation (e.g., interviews and surveys) rely on the user' s memory, which may be quite different from their actual behavior. Methodologies which can be applied in the study of health information systems in both the laboratory and real lif e settings include:

Usability Testing - evaluation of information systems involving subjects who are representative of the target user population:

Cognitive Task Analysis - characterization of the decision-making and

reasoning skills of subjects as they perform activities involving the

processing of complex information; and

Computer Supported Video Analysis - video recording of subjects as they interact with user interfaces in carrying out specific tasks.

Kushniruk eta! (1997) reported that while cognitively-based usability testing can be applied throughout the lifecycle of information systems, their experience to date has found that the greatest benefits come from formative analysis work.

Kushniruk (2002) suggests that future evaluation efforts with health information systems should integrate approaches which examine process variables and address measurement of outcomes.

Project Review and Objective Evaluation for Electronic Patient and Health Records Projects (PROBE)

The PROBE report, prepared by the National Health Service (NHS) in the UK,

describes a practical approach for the evaluation of Electronic Patient and Health

Records. PROBE identifies four (4) core standards for an evaluation study which

need to be considered throughout the planning continuum: utility, feasibility,

propriety and accuracy. The key principles of evaluation emphasized are the need

for both formative and summative approaches, advance planning, close

integration to the project lifecycle, clearly defined aims and objectives, the

inclusion of a before and after element, and the use of quantitative and qualitative

data. Six steps are proposed when planning an evaluation: ( 1) agree why an

evaluation is needed, (2) agree when to evaluate, (3) agree what to evaluate, (4) agree how to evaluate, (5) analyze and report, and (6) assess recommendations and decide on actions.

Total Quality Management (TQM)

Drazen and Little (1992) argue that new approaches are needed to evaluate health information systems in order to measure benefits that are important to the institutional sponsors. Enhancements to the traditional approach to evaluation include: (1) measuring benefits beyond cost savings, (2) focusing on critical issues and using standard tools to achieve efficiencies, (i.e. measure what is important, not what is easy to measure), (3) maintaining independence, given the involvement of the private sector in many of the evaluation initiatives, and ( 4) fitting with the institutional philosophy.

Total Evaluation and Acceptance Methodology (TEAM)

The TEAM evaluation approach (Grant et al, 2002) for information systems is

based on a three dimensional framework : Role, Time and Structure. The role

dimension identifies four main categories: designers, specialist users, end users

and stakeholders. The time dimension has four main phases throughout the

continuum of information system development: design, prototyping and testing;

evaluating prototyping of the system; evaluation after a maturing period; and ongoing periodic evaluation. The structural dimension distinguishes strategic, tactical or organizational, and operational levels. Key characteristics of this methodology include the insistence on a global rather than partial approach to the evaluation, and the recognition of the dynamic nature of information systems.

Health Technology Assessment

Kazanjian and Green (2002) propose a Health Technology Assessment framework as a conceptual tool for decision-making specific to health technologies. Impacts are considered at the societal level and from the perspective of patients as primary stakeholders. The framework dimensions include: (1) population at risk, (2) population impact, (3) economic concerns, (4) social context, and (5) technology assessment information.

Framework/or Action Research

Action research gives emphasis to doing research with and for people, as opposed

to on people. The goal is to create knowledge about a social system and then, as

part of the research process, use this knowledge to change the system (Meyers,

2001 ). Action research has been used in social sciences since the 1940s , however

it is generally not employed for evaluating information systems (Lau 1999). Lau

put forward four dimensions of an evaluation: (I) a conceptual foundation, (2) a study design to describe the methodological details, (3) the research process of diagnosis, actions, reflections and general lessons, and (4) the respective roles of the researcher and participants. Four main role categories are identified: (1) those involved in the conception and design of the information system, (2) those who are responsible for the implementation and functioning of the system (specialist user), (3) those who use the system, and (4) those who have a vested interest that the information system is a success. There is a requirement for consensus of evaluation priorities from all stakeholder perspectives and a recognition of the limitations of an evaluation process so that the evaluation is considered both valid and achievable.

Balanced Score Card

The balanced scorecard (BSC) is a means to evaluate corporate performance from

four different perspectives: the financial perspective, the internal business process

perspective, the customer perspective, and the learning and growth perspective

(Kaplan and Norton, 1992). Investments in health information systems are costly

and it is necessary to quantify the success of such systems and the degree to

which the investment was justified (Protti, 2002). Challenges to addressing these

concerns include: (1) efficiency (doing things right) is easier to measure than

effectiveness (doing the right thing), (2) new systems are intended to change

difficult to measure actions, (3) strategic systems elude measurement, and (4) infrastructure investments can not be justified on a Return on Investment (ROI) basis.

2.2 Evaluation Perspectives

Perhaps the most widely known approach used in health related research is the Randomized Control Trial (RCT). An RCT is a scientific approach used in the testing of the efficacy of medicines or medical procedures. It is widely considered the most reliable form of scientific evidence because it eliminates many of the biases that often are unavoidable in approaches commonly used in benefit evaluations. However, the use of RCT's in evaluating the benefits of health technology is impractical, given the problems with randomization (Heathfield et a!, 1997; Heathfield et al, 1999; Burkle eta!, 2001), blinding (Burkle eta!, 2001), costs (Moehr 2002; Heathfield et a! , 1998), and sample size (Burkle et a!, 2001 ; Moehr 2002).

Deciding on the evaluation approach to take will be influenced by a number of

factors, including the individual disciplines comprising the research team and the

trade offs between the options available (Heathfield et a!, 1999). A summary of

various perspectives on evaluation approaches used in health technology is

provided:

Objectivist versus Subjectivist

Friedman and Wyatt ( 1997) first put forward the objectivist versus subjectivist perspective. The objectivist researcher: (I) is in agreement as to which dimensions of a system are important to measure, (2) believes that a " gold standard" exists that can be compared against a standard measure, and (3) believe that benefits of the system can be measured using quantitative methods. The subjectivist researcher feels that: (1) there are differing views on what is important to measure, (2) there is no "gold standard" for which to compare to, and (3) qualitative methods are used to understand the different opinions and conclusions reached by different observers in the same setting.

Formative Versus Summative

Formative evaluation occurs while a system is still under development and

findings can be used to modify the system prior to completing the

implementation. The role of the researcher is to provide results to those

involved in the evaluation in order to inform ongoing program planning,

development and refinement. Summative evaluations occur after a system has

been implemented and are used to determine what has been achieved as a

result of the program (Ammenwerth et al, 2003). These results could include

outcomes and impacts, attainment of goals, unanticipated consequences, and

possibly comparisons with alternative programs in terms of efficiency and effectiveness.

Scientific Versus Pragmatic

Scientific studies are designed to meet a set of standards set out by peers in

their field and the value of their work is judged against these standards (Rossi

and Freeman, 1993). Evaluation methods are ranked according to their ability

to link cause and effect while controlling for both internal and external

validity. The randomized clinical trial (RCT), which was previously

discussed, is considered to be the "gold standard" method for scientific

research (Cook and Campbell, 1979). The " pragmatic" evaluation recogni zes

that while scientific investigations and evaluation efforts may us e the same

procedures , the intent of pragmatic evaluations is to (a) produce maximally

useful evidence within the specified budget and time (Cronbach, 1982) and

(b) address the interests of the sponsors and other key stakeholders (Rossi and

Freeman, 1993).

Accountability, Developmental and Knowledge Perspectives

Heathfield and Pi tty ( 1998) proposed three (3) separate categories of perspectives with respect to evaluations: accountability, developmental, and knowledge.

Accountability perspective: to answer the question about whether a particular intervention caused a particular outcome. Such an approach usually involves the use of summative and quantitative methods.

Developmental perspective: to strengthen institutions, improve agency performance or help managers with their planning, evaluating and reporting of tasks. Usually involves formative evaluation methods and is often qualitative, but can be quantitative.

Knowledge perspective: to acqutre a more profound understanding of

some specific field. Depending on the academic discipline of the

researcher involved, it can employ both qualitative and quantitative

methods.

2.3 Challenges to Evaluation ofEHR Initiatives

An extensive review of the literature did not locate any studies which evaluated the benefits of a comprehensive EHR. A comprehensive EHR is one that spans multiple systems across geographically dispersed service areas. Most studies that investigated the benefits of health information system implementation were of limited scope, in that they focused on small scale initiatives, such as when new technologies replaced existing administrative (usually paper-based) systems (Chaudhry et al, 2006; Heathfield et al, 1997), or when a study investigated at most two components of an EHR, such as the interface between pharmacy and laboratory systems (Ammenwerth, 2003). The settings for evaluations were also limited, in that most were carried out within a single hospital department, or focused on a specific hospital to physician office communication link (e.g. , accessing lab results).

A possible explanation for this gap in the literature is that there are limited

comprehensive EHRs implemented worldwide to evaluate. Historically, a lack of

interest by government decision makers (i.e. , funders) in establishing EHRs as a

fixture in the management and delivery of health services significantly slowed

their implementation. If governments do not consider EHRs a strategic

investment, difficulties in evaluating the impact of such initiatives will be

compounded by the lack of progress in their implementation (Healthfield and

Buchan, 1996). This has resulted in an interesting paradox; governments require evidence to support the investment of millions of dollars in EHRs, yet without implementing the systems and evaluating its benefits, researchers cannot deliver on the evidence needed by governments to support funding for their implementation (Healthfield 1999). A second possibility for the lack of evidence, although difficult to substantiate, is that comprehensive EHR studies may have been undertaken, but because they were not successful, they were not published (Healthfield, Pitty and Hanka, 1998; Tierney and McDonald, 1996).

Defining an EHR

Compounding the issue of having relatively few fully functional EHRs to evaluate, is the diversity in definitions of an EHR (Ash and Bates, 2005 ; Heathfield et a!, 1999). To illustrate this divergence in EHR definitions, a summary of four major national EHRs strategies (i.e., United Kingdom, Australia, United States, and Canada) that have been, or currently are being, implemented is provided:

United Kingdom

The National Health Service (NHS) Connecting for Health initiative is an

agency of the Department of Health in the United Kingdom and is responsible

for incorporating new information technologies into the various health regwns. The Connecting for Health initiative includes the following components of an EHR: 1) Electronic Scheduling, 2) Computerized Physician Order Entry, 3) PACS, 4) secure e-mail system, and 5) Quality Management and Analysis System. By 2010, the National Programme for IT estimates connectivity in England of over 30,000 GPs and almost 300 hospitals.

(http: //www.connectingforhealth.nhs.uk/publications/its coming leaflet.pdD.

Australia

Australia's EHR initiative is being implemented under the HealthConnect initiative and is considered a virtual network, in that it utilizes change management strategies that support the communication of health infonnation in an electronically shared health system. HealthConnect encourages individual health information to be collected in a standard electronic format at the point of care, such as a hospital or doctor's office. An event summary at these points of care is then generated and could include information on the patient intervention including treatments, discharge summaries, test results, and prescribed medications.

(http://www.health.gov.au/intemetlhconnect/publishing.nsf /Content/fags-

llp#6)

Veterans Health Administration (United States)

The Veterans Health Administration (VHA) is the largest integrated health system in the United States and provides medical , prescription, surgical, and rehabilitative care for US veterans. The VHA EHR initiative consists of a computerized patient record system (CPRS) which is fully operational at all medical centers and most other VA sites of care. The CPRS provides access to online patient records that integrates medical chart information with various medical images such as x-rays, scanned documents, and exam results (Prelin eta!, 2004).

Canada

In Canada, the national EHR initiative is the responsibility of Canada Health

Infoway (lnfoway), which is funded by the federal government. In 2002,

Infoway described the functionality (or domains) of an EHR to include a: ( 1 )

unique provider/client registries, (2) pharmacy network , (3) laboratory

network, and (4) diagnostic imaging. In 2003 , two additional domains were

included: 5) telehealth and 6) public health surveillance. Given all 1 3

jurisdictions in Canada are at different levels of EHR implementation with

respect to these domains, lnfoway is currently focused on implementation at

the jurisdictional level. As jurisdictions continue to make advances with